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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 111:11 _ S 26182 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. _ . q 6-) e ) S Lab. No.(s) <br />Sample Date 2 S lr)Ic) Time I X O') Date Data Entered <br />Collected By /S?,•, ,. -z.__"" Data Entry By <br />Field Custodians Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.va?ci VL'JllO LCJLILQLIUU <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water Soil Other (specify); <br />2. Analysis - Test series requested: <br />•? .S ??1 y ,?/ z? <br />3. Field Data -Preservation: 87 <br />Al Al.( ) <br />.? 7 <br />4. Date analysis required by (if not Holding Time): _ <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />( ) Check.-if additional attachments. <br />aiMl?r . <br />QA Review: '"' ?--- <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />) and explain below. <br />Page 42 of 44